The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

A client who delivered vaginally 18 hours ago develops a slight fever. The client’s delivery record shows spontaneous rupture of membranes (SROM) for 36 hours prior to delivery and labor lasting 24 hours. An epidural was placed during labor, and she experienced a third-degree perineal laceration. The nurse should recognize which information poses the greatest risk for developing postpartum endometritis?

The nurse observes a fetal heart rate pattern on the monitor: baseline 160 beats per minute with minimal variability, a decrease to 150 beats per minute beginning after the contraction starts and returns to baseline after the contraction ends. Which finding should the nurse document in the electronic medical record?

A nurse is caring for a primiparous client in the postpartum unit. The client was induced at 41 weeks gestation with misoprostol and oxytocin and gave birth vaginally 4 days ago. She was discharged home on day two with her newborn and has been breastfeeding around the clock. She called her healthcare provider this morning with fatigue, new-onset headache, nausea, dizziness, weakness, and seeing "flashing lights."

Exhibits:

The nurse reviews the client's history, physical, and flow sheet to determine the cause of the client's symptoms. Highlight the information from the history, physical, and flow sheet that require further evaluation. Select all that apply.

A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.”. Client was instructed to come to the hospital for evaluation.

The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?

A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)

A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?